Resident 53 told inspectors she was continent when she arrived at the facility but received a PureWick external catheter because she was non-weight bearing for several weeks and staff didn't want her getting up to use the toilet. The device remained in place even though her medical record contained no order for it and her care plan made no mention of catheter use.
When inspectors observed the resident's room on January 26, they found a suction canister on her bedside table with tubing containing dark amber fluid. The resident explained that staff changed the PureWick device several times per week.
"I was continent when I came to the facility," she told inspectors, "but was non-weight bearing for a few weeks and was given a PureWick catheter to use so I did not have to get up to use the toilet."
The facility's own nurses acknowledged the device required a doctor's order that never existed.
"PureWicks should have a doctor's order," Registered Nurse 2 told inspectors. She said the resident had been using the device for a couple of weeks because "resident 53 did not want to have brief changes and was non-weight bearing for a couple of weeks."
The nurse added that she had received no training from the facility on PureWick use and was unsure how often the device should be changed.
Staff gave conflicting information about the catheter's management. Certified Nursing Assistant 1 said the resident wore briefs in addition to the PureWick. Registered Nurse 3 stated the device should be changed every 24 hours with the canister cleaned weekly, while the resident said staff changed it only a few times per week.
The CNA Coordinator described PureWick use as "a newer thing" at the facility and said nursing assistants had received training on the device. However, RN 2's statement contradicted this, indicating nurses lacked proper instruction.
Director of Nursing acknowledged the violation during her interview with inspectors. She confirmed resident 53 had used the PureWick for two weeks without the required physician's order and agreed the device should have been included in the resident's care plan.
The DON explained they had tried using a bedpan for the resident, "but she did not like it." She described the PureWick as providing "dignity" for the resident during her period of being bed-bound and non-weight bearing.
By the time of the inspection, resident 53 had regained weight-bearing status and was participating in physical therapy, yet continued using the unauthorized catheter.
The PureWick system uses gentle suction to draw urine away from the body through an external collection device, marketed as an alternative to traditional catheters for women. While less invasive than internal catheters, the devices still require medical oversight and proper protocols.
Federal regulations require nursing homes to provide appropriate care for continent residents and help them maintain continence unless their clinical condition makes it impossible. The regulations also mandate that all medical devices be ordered by physicians and incorporated into residents' care plans.
The facility's failure extended beyond the missing order. Staff demonstrated inconsistent knowledge about device management, from changing schedules to cleaning protocols. The lack of standardized training raised questions about whether other residents might be receiving similar unauthorized treatments.
Resident 53's case illustrates how facilities sometimes prioritize convenience over proper medical protocols. Rather than ensuring adequate staffing to help a continent resident reach the bathroom or developing an appropriate toileting plan during her non-weight bearing period, staff opted for an unauthorized medical device.
The inspection occurred following a complaint, though the specific nature of that complaint was not detailed in the violation report. Inspectors reviewed 30 resident cases and found this single instance of unauthorized catheter use, suggesting the problem may be limited in scope but significant in its implications for medical oversight.
The violation received a "minimal harm or potential for actual harm" rating affecting few residents. However, the use of any medical device without proper authorization represents a fundamental breakdown in clinical supervision that could have led to complications including urinary tract infections or skin breakdown.
Resident 53 remained at the facility using the unauthorized catheter as inspectors completed their investigation, with no indication in the report about immediate steps to address the situation or obtain the required physician's order.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pinnacle Nursing and Rehabilitation Center from 2026-01-29 including all violations, facility responses, and corrective action plans.
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